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  • New Rules for ACOs Aim to Encourage Participation

    Accountable care organizations (ACOs) participating the Medicare Shared Savings Program (MSSP) will begin operating under some new rules designed to incentivize participation in the program while continuing the Centers for Medicare and Medicaid's (CMS) evolution toward value-based payment.

    Under the new rule, ACOs that sign up for a second or subsequent contract period will be subject to a benchmarking process based on regional rather than national spending data—a move aimed at acknowledging the fact that health care costs aren't the same across the country. Also, so-called Track 1 ACOs (which share in savings but are not responsible for losses) that are approved for renewal will be allowed more time to transition to a risk-based Track 2 or 3 model by way of a 1-year deferment.

    The rule also sets up a 4-year window for appeals and reopenings of reviews of savings or losses—the first time CMS has offered specifics on the process.

    APTA has developed summary of the rule and offers a webpage dedicated to ACOs. Also, the APTA Learning Center includes a recorded webinar on ACOs and the role of physical therapists.

    "Today's changes will encourage more physicians to improve patient care by joining [ACOs], while also refining how the program measures success, so that current participants are better rewarded for quality," said CMS Acting Administrator Andy Slavitt in a news release.

    The rule will be implemented in phases beginning January 1, 2017.

    CMS Will Shift Home Health Agencies to a 'Pre-Claim Review' Model in 5 States

    In a step that it hopes will help educate home health agencies (HHAs) and prevent improper payment, the Centers for Medicare and Medicaid Services (CMS) will soon require HHAs in 5 states to participate in a pre-claim review process for their Medicare patients.

    Beginning with Illinois on August 1, 2016, CMS will require HHAs to submit supporting documentation for services while beneficiaries are receiving care. CMS will review the pre-claim and make a review decision "generally within 10 days," according to a CMS fact sheet. The other 4 states—Florida, Texas, Michigan, and Massachusetts—will be phased into the program during the rest of the year and into 2017.

    According to CMS, the documentation will be "the same type of documentation [HHAs] currently gather for payment, only HHAs will submit it earlier in the process." The new program does not change eligibility standards, and CMS states that it will allow HHAs to submit additional pre-claim documentation to support the claim should CMS find the initial submission lacking. HHAs can receive initial payments before CMS makes its pre-claim review decision, and if a claim is not approved during the pre-claim process, the HHA can appeal.

    Once the program has been operational for 3 months in a demonstration state, HHAs that submit a claim without a pre-claim review may still receive payment, but at a 25% reduction of the full claim amount—if they they are approved at all. These claims will go through the same pre-claim review process and may be subject to denial.

    The new program is an attempt to tighten up an HHA claims process that reached a 59% improper payment rate in 2015, with a large proportion of those improper claims linked to insufficient documentation. "The pre-claim review demonstration will help educate HHAs on what documentation is required and encourage them to submit the correct documentation," CMS states.

    The project is also designed to shift CMS away from a "pay and chase" approach that forces the agency to demand repayment of money already spent and toward a more preventive model. According to CMS, "most" of the 5 states targeted for the demonstration project have been identified as at "high risk" for improper payment.

    APTA will monitor implementation of the program to evaluate its effects on access to physical therapy, and will work with other stakeholders to ensure that CMS does not unfairly penalize all HHAs and the physical therapists who practice in home health settings.

    Improved Direct Access to PTs Now Law in Louisiana

    After a sometimes-contentious struggle, individuals in Louisiana now have improved direct access to physical therapist (PT) services.

    On June 6, Louisiana Gov Bel Edwards signed SB 291, which allows PTs to treat without a referral or previous medical diagnosis for up to 30 calendar days, a significant improvement over what had been one of the most restrictive direct access laws in the country. After 30 days, a direct access patient must be referred to a physician, dentist, podiatrist, or chiropractor if there is no measurable or documented functional improvement of the patient. The legislation was sponsored by state Sen Fred H. Mills Jr (R) and advocated by the Louisiana Physical Therapy Association (LPTA).

    All physical therapists who have a DPT or 5 years of clinical practice experience are eligible for direct access.

    The win for citizens and Louisiana PTs was not an easy one: opponents of the bill, led by the state's orthopedic surgeons association, launched an active campaign to block passage, arguing that direct access would put patients at risk should a PT miss a health condition that would require attention from a physician. In the end, the bill passed in both the Louisiana House and Senate by wide margins.

    “The passage of SB 291 and allowing the citizens of Louisiana to choose physical therapy directly was by far the most widely debated bill of the 2016 legislative session," said Cristina Faucheux PT, LPTA legislative chair. "Its passage paves the way for the citizens of Louisiana to have unparalleled services and be in the driver’s seat of their health care dollars."

    PTs Added to Bill That Protects Providers Traveling With Sports Teams

    A bipartisan bill that helps to protect health care providers who travel with sports teams now includes physical therapists (PTs) in its list of covered professions, and is poised to move on for consideration by the full Energy and Commerce Committee (ECC) and, eventually, the floor of the US House of Representatives.

    The Sports Medicine Licensure Clarity Act (HR 921/S 689) cleared an important hurdle this week when it was reviewed and approved in a markup session of a subcommittee of the ECC. The bill aims to provide added legal protections for sports medicine professionals when they're traveling with professional, college, or national sports teams by extending the provider's "home state" malpractice and professional liability insurance to any other state the team may visit.

    Originally, the bill's coverage was restricted to only physicians and athletic trainers. Advocacy staff at APTA worked closely with the office of Rep Brett Guthrie (R-KY) and ECC subcommittee staff to get PTs added to the list. The bill also opens the possibility of coverage for physical therapist assistants who are under the direct supervision of a PT.

    In addition to Guthrie, cosponsors include Cedric Richmond (D-LA) in the house, and Sens James Thune (R-SD) and Amy Klobuchar (D-MN).

    Upcoming 'Insider Intel' Program Gives You the Latest on Manual Medical Review, MACRA, IMPACT, and More

    APTA's popular "Insider Intel" call-in program returns on June 15 to deliver need-to-know information on hot topics in policy and payment.

    Free and limited to APTA members only, the upcoming session will focus on the proposed Medicare and Chip Reauthorization Act (MACRA) highlights, the new therapy cap-targeted manual medical review process, and payment reform for postacute care providers established through the Improving Post-Acute Care Transformation Act (IMPACT). APTA regulatory affairs staff will provide the latest information on the changes now in place as well as the ones to come, and callers will also have the opportunity to ask questions.

    The 30-minute call-in program will begin at 2:00 pm, ET. To register for a spot in the session, email advocacy@apta.org with "June 15 Call" in the subject line. Don't wait—space is limited, and the sessions typically fill up quickly. "Insider Intel" is free to members of APTA.

    If you're unable to participate live, recordings of the calls will be posted on a special Insider Intel page on the APTA website.

    APTA 2016 House of Delegates Election Results Announced

    The following members were elected to APTA's Board of Directors and Nominating Committee on Monday at the House of Delegates in Nashville, Tennessee.

    Roger Herr, PT, MPA, was elected secretary.

    Stuart Platt, PT, MSPT, was reelected vice speaker.

    Carolyn Oddo, PT, MS, FACHE, and Sue Whitney, PT, DPT, PhD, NCS, ATC, FAPTA, were reelected director and Kip Schick, PT, DPT, MBA, was elected director.

    Holly Clynch, PT, DPT, MA, GCS, and Chris Petrosino, PT, PhD, were elected to the Nominating Committee.

    These terms become effective at the close of the House of Delegates on Wednesday.

    Prescription Drug Prices, Rising Out-of-Pocket Expenses Help Push Average Family Health Care Costs to $24.6k per Year

    The squeeze continues: according to a new report, the cost of health care for a typical family of 4 covered by typical employer-sponsored preferred provider organization (PPO) has more than doubled over the past 10 years, with employees experiencing a faster rate of increase than employers, thanks to higher out-of-pocket demands and rising employee payroll deductions.

    The 2015 Milliman Medical Index report pegs the average cost of health care for a family of 4 at $24,671—that's a 6.3% increase, and a noticeable uptick from 2014's 5.4% increase, one of the lowest recorded by Milliman since it began its studies in 2001.

    Milliman points to a rise in prescription drug prices as the biggest reason for the increase, a category that grew by 13.6% from 2014 to 2015. According to the report, the increase was fueled by wider use of specialty drugs—drugs that cost more than $600 per prescription—and more demand for compounded drugs. Overall, prescription drugs accounted for 16% of a family's health care costs.

    And families are not seeing any relief in terms of the way costs are covered. Though at 58%, the employer contribution continues to bear most of the health care costs of employees, the rates of cost increase between employers and employees from year to year have not been equal, with employer costs rising by 5% in 2015, compared with an 8% rise for employees. Milliman estimates that the average family now pays about $10,473 per year, made up of $6,408 in employee payroll deductions and $4,065 in out-of-pocket costs.

    In terms of overall costs, care provided by physicians or other professional services accounted for 31% of the total amount, with inpatient care representing another 31%. Outpatient services were estimated at 19% of costs. Prescription drugs (16%) and "other" (4%)—such as durable medical equipment, supplies, ambulance, and home health—made up the rest of the cost scenario.

    Continuing a years-long trend, inpatient facility costs were again lower than average overall increases in health care costs, at 5.4% compared with 6.3%. Outpatient costs outpaced the average, with a 7% increase in 2015, though Milliman states that this rate represents a slowdown from the average 9.9% increases over the previous 5 years.

    News of the latest Milliman report was picked up by several media outlets, including Forbes, Money magazine, and CNBC.

    Extended PT Workforce Projections Include Scenarios Ranging From Shortage to Oversupply

    While there are plenty of variables that could lead to different outcomes over the coming years, the latest APTA models of future supply and demand for physical therapists (PTs) include a first: the possibility of an oversupply of PTs by 2025. Whether that particular scenario plays out will depend largely on the rate at which PTs leave the workforce between now and then.

    The latest projections, now posted on APTA's Physical Therapy Workforce webpage, run a limited number of variables through 3 different models of PT annual attrition rates between 2015 and 2025: 3.5%, 2.5%, and 1.5%--rates that were used in projections dating back to 2011. The 3 models are used because there are no studies that have established a definitive attrition rate for PTs.

    Plugging in those rates, the 2015 model anticipates that there will be a nationwide shortage of 18,350 PTs by 2025 if attrition occurs at a 3.5% rate. That shortage flips to a 736-PT surplus should the attrition rate occur at 2.5%, and grows to a surplus of 21,494 PTs at the 1.5% rate.

    The latest projection figures continue a general trend toward a predicted shrinking shortage of PTs that has surfaced over the past 2-3 years. The 2013 model included a shortage of 27,822 PTs at the 3.5% rate by 2020; that shortage dropped to 26,969 in 2014 under the 3.5% rate. Similarly, the 2013 model using an attrition rate of 1.5% predicted a 2020 PT shortage of 1,530, but in 2014, that estimate had declined to 606. The latest report pushes those trends out another 5 years, to 2025.

    The model has its limits: it does not factor in the impact of shifting demographics—such as the aging of the baby boomer generation—into its demand calculations, nor does it account for regional variables in demand for PTs. Also not included in the model: possible variations in supply and demand according to types of PT practice.

    Besides attrition, several other projections affect the supply-and-demand scenarios. The model anticipates an annual 4% growth rate in PT graduates, a 1% National Physical Therapy Exam failure rate, an annual addition of 535 internationally trained PTs entering the workforce, and a constant rate of 85% of all PTs being employed full time, with the remaining 15% being employed part time at an average of 24 hours per week.

    While an increase in the number of individuals with health insurance did provide some offset to the trend toward a surplus, expectations are for a levelling-off of that increase over the coming years.

    New Targeted Manual Medical Review System: 6 Things You Should Know

    The much-anticipated changes to the way the Centers for Medicare and Medicaid Services (CMS) conducts its manual medical reviews (MMRs) are under way, with the first round of requests for additional documentation (ADRs) now being sent to providers (here's a sample ADR).

    Here's what you need to know:

    1. The new system targets behaviors.
    The old MMR system was automatically triggered when a provider exceeded the $3,700 mark. The new one does not require MMRs for all claims exceeding the threshold, and instead takes a targeted approach, looking at providers who have provided a high amount of hours or minutes of therapy to patients in a single day.

    2. The reviews fall into 3 practice setting buckets: skilled nursing facilities (SNFs), private practice, and outpatient facilities.
    Home health part B claims aren't a part of the review process.

    3. ADRs will be limited to 40 claims per provider.
    Each claim will be reviewed; some may be upheld and others denied.

    4. The review contractor has 45 days to respond with its decision.
    CMS has contracted with Strategic Health Solutions (SHS) to serve as the supplemental medical review contractor (SMRC). This is who you'll be dealing with initially should you receive an ADR. Once you submit your information, the SMRC has 45 days to get back to you with a decision. After that, the SMRC will take no further action—though it can turn things over to the Medicare administrative contractor for further review.

    5. A "discussion period" allows you to fix errors or add information to the files you submitted.
    Making these changes could help you undo a denial. The discussion period is roughly 30 days, but you must request it.

    6. The process includes comparison with peers.
    Part of SHS's process for determining whether a billing process is potentially aberrant involves comparing providers who are doing the same thing—PTs in private practice, for example.

    The targeted MMR process is part of a wave of changes associated with the Medicare and CHIP Reauthorization Act (MACRA), a sweeping law that addresses payment issues in the aftermath of the repeal of the sustainable growth rate (SGR). APTA is developing a series of fact sheets on MACRA and will continue to monitor the new MMR process and provide updates as more information becomes available.

    CMS Offers Training on Coming IRF Changes

    Changes to reporting requirements for inpatient rehabilitation facilities (IRFs) are coming this fall, and the Centers for Medicare and Medicaid Services (CMS) is helping providers prepare.

    Now available for free download from CMS: presentation slides from a recent 2-day workshop that explored the ways that reporting on everything from functional abilities to falls will change under rules that implement portions of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act. That law, passed in 2014 and supported by APTA, seeks to standardize data collected across postacute health care settings. The new reporting requirements begin October 1, 2016.

    Originally presented as a "train-the-trainer" event in mid-May, the meeting's agenda and all slides can be found by scrolling down the CMS IRF Quality Reporting Training webpage to the Downloads section. The compressed files, all pdf versions of PowerPoint slides, are labelled "IRF Training" 1, 2, and 3. Recordings of the training sessions will be posted to the CMS YouTube site in several weeks.

    Topics include an overview of the changes and more detailed information on reporting requirements around functional abilities and goals; falls; swallowing and nutritional status; skin conditions; hearing, speech, and vision; bladder and bowel; cognitive patterns; and special treatments, procedures, and programs. Slides also cover active diagnoses, and IRF-PAI (patient assessment instrument) data submission and Certification and Survey Provider Enhanced Reports (CASPER).